Health Education Research, Vol. 15, No. 5, 603-614,
October 2000
© 2000 Oxford University Press
Adapting a natural (lay) helpers model of change for worksite health promotion for women
Department of Community Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV 26506, and
1 Center for Health Promotion and Disease Prevention,
2 Department of Nutrition, School of Public Health,
3 Center for Development and Learning, and
4 Department of Health Behavior and Health Education, School of Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
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Abstract |
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Social network interventions that utilize informal systems of helping can be an important strategy for health promotion change. This article describes the development, implementation and evaluation of a natural (lay) helping intervention for health promotion change, specifically designed for women in small rural blue-collar worksites. One hundred and four women in four intervention worksites were recruited as natural helpers, and received health and skill-building education over an 18-month period. Qualitative evaluation showed: (1) two patterns of natural helping for women, i.e. participation due to a specific health concern with either themselves or others in their personal networks, and participation due to a larger sense of the importance of health and prevention; (2) over time natural helpers expanded the diffusion of health promotion information from close network members to co-workers and were more likely to be approached by their co-workers for information; (3) group activities at the worksite, particularly around physical activity, increased over time; and (4) because of time constraints at the workplace, written materials were a major way of spreading information to co-workers. This study shows that women can be recruited and trained to diffuse health promotion information and provide support to co-workers for health behavior change.
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Introduction |
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Studies consistently point to the importance of strong social ties and supportive social relationships in influencing health-related behaviors, and both mental and physical health (McKinlay, 1973
; Berkman, 1995). For example, social ties have been shown to be beneficial in relation to weight control (Marcoux et al., 1990), dietary change (Kelsey et al., 1996), smoking cessation (Romano et al., 1991) and cancer screening (Kang et al., 1994). Given the strong evidence for a relationship between social networks, social support and health outcomes, more attention is warranted for implementing interventions at the level of the social network (Berkman, 1995), and, for women, acknowledging and utilizing the strength of their interpersonal networks (Marshall et al., 1995).
One such social network intervention strategy is a natural (lay) helping model of change. This intervention strategy aims at enhancing the ability of individuals to help each other through their own personal social networks (Collins and Pancoast, 1976; Service and Salber, 1979; Israel, 1985). This cultural model builds on the strengths within a community or cultural group, and considers the influence of naturally existing sources of social and community support (Levin and Idler, 1981), going beyond an individual level of change to increase social norms for health promotion and promote systems change (Eng and Young, 1992).
Interventions based on the concept of natural helping have been conducted for a variety of health issues and populations, many of which have focused on women. These include providing information about, and general access to, educational and screening services (Service and Salber, 1979; Hale et al., 1997), providing health services to mothers and children (Meister et al., 1992; Beam and Tessaro, 1994; Watkins et al., 1994), increasing cancer screening (Davis et al., 1994; Suarez et al., 1994; Bird et al., 1996; Earp et al., 1997; Navarro et al., 1997; Sung et al., 1997; Sharp et al., 1998), dietary change (Campbell et al., 1999) and for smoking cessation (Lacey et al., 1991; Stillman et al., 1993). The focus groups of many of these natural helping programs have been low-income (Lacey et al., 1991; Meister et al., 1992; Hale et al., 1997; Navarro et al., 1997; Suarez et al., 1997; Tessaro et al., 1997) and ethnic minority populations of African-Americans (Lacey et al., 1991; Stillman et al., 1993; Davis et al., 1994; Earp et al., 1997; Sung et al., 1997; Campbell et al., 1999), Hispanic/Latinos (Meister et al., 1992; Suarez et al., 1994; Bird et al., 1996; Navarro et al., 1997) and Native Americans (Sharp et al., 1998). Churches have been the focus of several of these interventions (Stillman et al., 1993; Davis et al., 1994; Campbell et al., 1999).
A number of worksite health promotion programs have recognized the importance of social support for facilitating behavioral change (Zimmerman and Connor, 1989; Fisher et al., 1994; Emmons et al., 1996). Women with high behavioral risk factors are especially likely to view the worksite environment as a supportive setting for health behavior change (Emmons et al., 1996). However, little attempt has been made to intervene at the social network level to foster socially supportive norms for health promotion and support change through the natural social networks in the workplace (Gottleib and McLeroy, 1994). This article describes the development, implementation and evaluation of a social network intervention using a natural (lay) helping model of change to promote health behavior change for women in worksites.
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Methods |
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Study design
Health Works for Women was a worksite health promotion intervention focusing on changing health behaviors associated with major causes of morbidity and mortality in women (smoking, high fat and low fruit and vegetable consumption, physical inactivity), and increasing breast and cervical cancer screening. An ecological framework was used to target multiple levels of change: (1) at the interpersonal level, a social network intervention utilizing the natural helping ability of women to support health promotion change at the worksite (Natural Helpers program), and (2) at the intrapersonal level, computer-generated individually tailored health messages designed to inform women about health risks and to provide feedback to initiate behavior change. Both components of the intervention were theory-based, using constructs from Social Cognitive Theory (Bandura, 1986
), Social Support Theory (Israel, 1985), the Health Belief Model (Strecher and Rosenstock, 1997) and the Transtheoretical Model (Prochaska et al., 1992). A pre-test–post-test two-group randomized research design compared four intervention and five control worksites on changes in the targeted health behaviors. Intervention worksites received both the tailored health messages and the Natural Helper program. Control sites received a delayed intervention consisting of the computer-generated tailored messages. Worksites were phased into the project over a period of 2 years from March 1995 to April 1997. The project was developed and implemented through the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill. This study was approved by the UNC School of Public Health Institutional Review Board.
Worksite and participant recruitment
The nine worksites in the study were recruited according the following eligibility criteria: (1) geographically located in a rural, eastern North Carolina county with a minority population of at least 30% of the total county population, (2) small to medium sized (125–350 employees), (3) blue-collar textile or light manufacturing industries, (4) employing a majority of women (at least 51% of workforce) and (5) no systematic health promotion program currently at the worksite. All worksites were identified and inventoried in the targeted counties to create a list of 132 worksites eligible for randomization. A total of 113 worksites were contacted but considered ineligible for several reasons: not enough women employees (n = 67), too many women employees (n = 1), plant closed or about to be closed (n = 15), had a comprehensive health promotion program (n = 8), not the right industry or county (n = 10), no permanent employees (n = 2), wrong county address or duplicate listing (n = 9) and no authority at the worksite to agree to a program (n = 1). Of the 19 eligible worksites, nine were not interested or would not set-up a meeting within the specified time period. The remaining 10 worksites were successfully recruited into the study, one as a pilot site and nine as study sites, and were randomized to intervention or control status. Of the nine study worksites, three were light manufacturing, and six were textile and apparel industries. Two of the intervention worksites were light manufacturing, and two were apparel and textile plants.
Quantitative evaluation: self-administered survey
Women were eligible to participate in the study if they were at least 18 years of age and spoke either English or Spanish (surveys were translated into Spanish). All women who agreed to participate completed the baseline self-administered survey and consent forms at the worksites. Surveys took approximately 30–45 min and women were given paid release-time from work to participate. Project staff were present to provide detailed instructions, answer questions and assist individuals with reading the survey as needed. At baseline, 859 women participated out of a total of 1168 eligible women working at the nine worksites for a participation rate of 73.5%. Study measures included demographic information (age, race/ethnicity, educational level), perceived health status, body mass index, social support and social network characteristics, and health behaviors of smoking, exercise and diet, and Pap testing and mammography for women age 40 and older. All women who completed the survey received computer-generated health messages tailored to their individual responses on the survey.
Development of the Natural Helpers program
Following administration of the baseline survey and prior to initiating the Natural Helpers program at each of the four intervention worksites, focus groups were conducted with women on all work shifts to better understand their health concerns and perceived barriers to promoting healthy behaviors, and to learn about the support available through women's social networks to assist in health promotion change. These focus groups were instrumental in plans to recruit natural helpers, in determining program content, and in developing the culturally tailored educational training materials and sessions (Tessaro et al., 1998).
Identifying and recruiting natural helpers
The goal for recruiting natural helpers was to assure that women from all work areas and networks of women were represented. We estimated this to be between five and 10 women per worksite, depending on the size of the worksite. Using methods suggested by Salber (Salber, 1979), women were identified by: (1) asking women in the baseline survey to name co-workers who others often turned to for help and support, (2) recommendations from management to assure the inclusion of all networks of women and work areas in the workplace, and (3) allowing women to self identify as someone with an interest in providing support and education to co-workers for health promotion change. This last method was important so as not to disrupt the close friendships and working relationships observed among the women at the worksites by excluding those who had an interest in helping co-workers but had not been named by the first two methods. Identification of natural helpers varied as more was learned about the worksites and recruitment. In worksites 1 and 2 women self-identified as having an interest in the program and management gave us feedback on additional women for the program to represent all networks and work teams of women in the plant. In worksites 3 and 4 all methods described above were used.
At each workplace, a recruitment meeting was held to explain the purpose of the program and to develop a plan for training. Flyers were posted at the worksite to invite women interested in becoming natural helpers. Women named through reputational methods were invited to attend by letter; about half of them agreed to become natural helpers. Women were asked to commit to attending all educational sessions, to disseminate the knowledge learned about health behavior change with co-workers, to offer support for behavior change and to work together as a group to develop health promotion activities for women in their work areas at the worksite.
Educational training sessions
Educational sessions were conducted by members of the project team, which included a nurse, nutritionists, health educators and graduate students in health education. These sessions were offered over an 18-month period on-site at the worksite and were scheduled immediately before or after the workshifts when it was most convenient for women. Each session lasted between 45 and 90 min. A participatory learning approach involving group discussion and activities, and techniques to enhance skills in the targeted behavior areas were adopted for the training sessions (e.g. low-fat cooking, exercising, stress management techniques). A contact person at each worksite was instrumental for assisting project staff in making arrangements for the sessions. Participation by all women was voluntary; natural helpers were not paid for their participation in the training sessions or activities related to their role as a natural helper. Table I shows the number of women who participated in the initial and subsequent educational sessions, and the average number of natural helpers attending each of the six education sessions by worksite.
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Women received education on: (1) the important role of support for making health behavior changes, (2) healthy eating, (3) fitness and exercise, (4) stress reduction, (5) women and cancer, and (6) weight management. Training materials included: (1) information about targeted health behaviors and health education materials appropriate for the women, (2) resources for health promotion in the local community, such as low-cost mammography screening sites or places for exercise, (3) skill-building information about providing emotional support, listening and helping with problem-solving, and (4) skill-building on how to work together as a group to organize worksite activities to promote healthy behaviors. Additionally, women received information about the health issues of concern to women at their worksite (from focus group findings), the prevalence of women's health-related behaviors (smoking, fat and fruit and vegetable consumption, physical activity) at their worksite from baseline survey findings, and barriers and facilitators cited by women for health behavior change. The issue of stress, although not originally targeted as part of the intervention, was incorporated into the sessions because of its repeated emergence as an issue of importance for women. The initial session at each worksite was developed around the health issue women identified as of most concern from the focus groups.
To recognize the special role of the natural helpers, a graduation ceremony was held after the completion of the initial training session. An article about the Natural Helpers program at each of the worksites, along with a picture of the women, was printed in the local newspaper to give recognition to the program and the women. T-shirts and tote bags for carrying the educational materials, inscribed with the Health Works for Women logo, were given to the women to assist them in their role as a natural helper by making them easily recognizable at the worksite.
Qualitative evaluation: structured interviews and field notes
To learn more about their roles as natural helpers, personal open-ended interviews were conducted with women 6 and 12 months after the initial educational training session and a group interview was conducted at 18 months when we exited each worksite. Observation and field notes during the time in the worksites provided additional insights into program development and experiences of the natural helpers. At Time 1 interview, 69 natural helpers were eligible to be interviewed; this included three additional women who participated in the educational training sessions after the initial training. Fifty-two of these women were interviewed (75.4%). Between the Time 1 and Time 2 interviews an additional 35 women participated in the educational sessions (see Table I
). At the Time 2 interview, 70 of the 104 natural helpers who participated in the training sessions were interviewed (67.3%). Eighty-two of the 104 natural helpers were personally interviewed at either 6 or 12 months (76.9%); 40 completed both interviews. Interviews were conducted on a day that worksite management allowed women off the line for the interviews. Women were not interviewed because they were out sick, on vacation/leave, were working the weekend, were no longer employed at the worksite or because of worksite constraints.
Questions for the individual interviews focused on: how information about health promotion was spread (initiated, approached; in conversation, written materials), to whom (family, co-worker, friend, etc.), how many others they shared information with, barriers to sharing information with co-workers and activities done as a group around targeted health issues. The group interviews asked about their role as a natural helper, awareness of the Natural Helpers program by co-workers, changes in health promotion activities at the worksite since the program began and how natural helpers would continue with the program after Health Works for Women left the worksite. All interviews were transcribed and analyzed by the authors (I. T., L. B. and S. T.) using descriptive methods of analysis. ETHNOGRAPH, a text analysis software package for microcomputers, assisted in organizing the data (Siedel et al., 1995). Interview data were coded using the initial organizing framework of the interview guide questions. Comparisons were made between worksites and across time periods.
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Evaluation |
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Quantitative data
Sociodemographic characteristics
Eighty-seven of the 104 natural helpers (84%) completed the project's baseline survey. The natural helpers were similar in age, ethnicity and education to their female co-workers (N = 417). They tended to be slightly older and more educated, but the difference was not statistically significant. However, natural helpers were more likely to come from the first shift than from other shifts (P = 0.001). There were no differences between those natural helpers who participated early (attended initial sessions) and those who subsequently participated. (Table II
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Health behaviors
Natural helpers were similar to their co-workers in self reported health status, body mass index and health behaviors (smoking, diet, cancer screening). However, those natural helpers who participated early in the training reported lower dietary fat consumption compared to those who participated later (P = 0.02). There was also a tendency for earlier participants in the training sessions to be non-smokers when compared to those who joined the program later. (Table III
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Social support/social networks
Natural helpers were as likely as their co-workers to be married or living with someone, to have children under 18 at home, and to belong to social and church groups. Natural helpers reported a similar social network size as their co-workers, but were significantly more likely to belong to a group for community betterment (P = 0.004), to say they could leave their work area to visit in other areas (P = 0.001) and to talk to others at work about health issues (P = 0.003). There were no differences in social network characteristics between those natural helpers who participated early and those who subsequently participated (Table IV
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Qualitative data
Natural helping role
Two distinct patterns emerged concerning the role of natural helpers at the worksites: (1) women who became involved and disseminated health promotion within a broader, more global conceptualization of health and prevention (prevention-oriented), and (2) women who became involved in the program and disseminated health promotion because of a specific health concern or event that involved them or others in their networks (health-issue oriented).
Twenty of the 82 natural helpers interviewed were classified as prevention oriented and participated in the Natural Helpers program due to a larger sense of the importance of health and prevention that went beyond just obtaining personal support for their own behavior change. This did not mean that they did not have an issue on which they were personally working, but their interest in the program went beyond themselves. Women often mentioned being sought out by others in their social networks. There were at least three of these natural helpers at each worksite. The majority of these 20 prevention-oriented natural helpers (N = 15) had been identified through reputational methods. Although they often diffused specific information about health promotion in response to a particular issue or situation, they also saw `the big picture' and encouraged others to think about their health in general and not just in terms of a particular illness or issue. The importance of healthy behaviors was recognized for others as well as for themselves. They just `naturally' diffused information to others, i.e. they approached others or they were approached because of their knowledge and wisdom. Information about health promotion was diffused to a larger number of people, with a wider dissemination (family, friends, co-workers, neighbors, church and other community members). They also seemed to do more health promotion activities with a buddy or in a group. In three of the worksites our liaison or contact person fell into this category. These women were the ones most readily identified as having the desired characteristics of a natural helper—being sought out by others, being in contact with many others. The following quotes from two women classified as prevention oriented illustrate this role:
Well, most of the time a lot of my co-workers would talk to me you know about problems and stuff that they would have and it's just that I seem concerned about everything and everybody. So anything that I can help someone with interests me.Oh, they come to me so many times to ask me. This is how it happens to me, people just volunteer to come to me automatic. Ask me about different things, like how do you keep your weight down or what do you do? One thing to another, you know.
Fifty-four of the 82 natural helpers interviewed were classified as health-issue oriented and appeared to participate in the Natural Helpers program primarily to promote individual health behavior change, either for themselves or to improve the health of a significant other or family member. This may have been a reaction to a specific health condition or life experience, or feelings of susceptibility to illness because of a risk factor. Thus, the benefits of being a natural helper are mainly to support personal health behavior change, although helping others was also mentioned. These natural helpers tended to diffuse information about health promotion to fewer people in their networks and their interactions were more responsive than proactive. Although some tended to volunteer information about health promotion, many did not do so unless they were asked directly as part of general conversation with those in their personal networks of family, friends and co-workers. They may or may not have done health promotion activities with a group. Two women classified as health-issue oriented explained why they became natural helpers:
I wasn't at first chosen to be one. But then with what I had gone through in my life I felt like I would, I feel like this is my ministry and where I need to be... So I feel like this is where I should be and for what I have been through and the experiences that I have had to be able to become a natural helper was great.My mother died when she was real young and I think that's why, because anything that I can learn about, I just love to learn anything about health so maybe I can help myself and help others.
Eight of the natural helpers could not be classified as either of these types. Although they did participate in the training sessions, they shared very little information with others and did not have any strong opinions about healthy behavior one way or the other. Rather, they seemed primarily to be attending because some of their co-workers were participating.
Diffusion of health promotion information
At the 6-month interview (Time 1) natural helpers reported they diffused information about health promotion most frequently to their immediate family. Besides spouses or boyfriends, this was done mostly with other women (daughters, mothers, sisters, aunt). Sharing information with co-workers was done to a lesser degree. By the second interview at 12 months (Time 2) the diffusion of information had expanded to include more frequent interactions with other co-workers, friends and community members (almost always at church). Diffusion of health promotion at Time 1 with co-workers was primarily described as interactions among the natural helpers themselves as they practiced skills learned in the training sessions and as they began to work together as a group. `Every time we had a session we go back and we'd talk about it for weeks and weeks.' For both the prevention-oriented and health-issue-oriented natural helpers diffusion of information increased from Time 1 to Time 2 with co-workers as well as others outside the workplace.
By Time 2 there were more frequent instances of co-workers approaching the natural helpers to ask about health promotion information from the educational training sessions. `We always talk about what we learned and the other people ask us. You know they get so they ask us more now what do we talk about.' At Time 1 prevention-oriented, more than health-issue-oriented, natural helpers reported that co-workers approached them for health promotion information, but by Time 2 there was little difference between the two types of natural helpers in how health promotion was diffused. Health-issue-oriented natural helpers were as likely to say that others had approached them for information as prevention-oriented natural helpers.
Information about health promotion was diffused mostly through general conversation with co-workers, rather than through proactively seeking co-workers out. `We are edging each other about what we eat and the fat grams. We keep it in conversation.' Written materials from the educational training sessions was a major way of spreading information about health promotion to co-workers and family members. Natural helpers preferred to share health materials (manuals, recipes, handouts) with co-workers on a one-on-one basis, although contact persons who saw it as part of their larger role at the company also mentioned utilizing bulletin boards and placing handouts by the time clock. At work, natural helpers shared information about dietary tips from the training sessions with co-workers most frequently at break time and lunchtime when they ate together.
Group activities
As part of the training sessions, natural helpers were encouraged to develop group activities related to targeted health behaviors that would fit into their work situation. Initially these activities were done on a limited basis, but increased with time as women began to use the skills they learned in the training sessions. By the second interview at 12 months, natural helpers were organizing and carrying out more group activities. Most group activities were exercise related, and generally occurred at lunchtime or after work at the worksite. Twenty-seven of the natural helpers reported in the interviews that they were involved in group activities, mostly walking with others as buddies or in a group. Women would meet to exercise on the plant floor or in the parking lot. At one of the worksites there was a lunchtime walking group that mapped out a trail around the outside of the plant. Natural helpers from two of the worksites participated in a local walkathon. Walking groups were not limited to the natural helpers; many of the women who did the walking were their co-workers.
Barriers to change
Time, in the form of overtime work schedules, conflicting work shifts, particularly evening and night shifts, or after-work family obligations, was the major barrier to diffusion of information about health promotion by the natural helpers and for getting together as a group for activities. `We just all wish we had more time to devote to ourselves and to do these things.' Because of these time limitations, written materials were often the preferred method of diffusing information about health promotion to women in their work areas, and breaks and lunch were the best times for dissemination. Natural helpers had limited time to talk to co-workers who were not in their immediate work areas. Since it was hard to leave their work areas, natural helpers shared with people in their own circles and work areas. `In time you are only going to interact with certain people. You get to do that every day with just certain ones. You really don't have time to break away and get out there.'
Program continuation
Many of the natural helpers felt they would continue with trying to make health changes in their lives and the lives of others once funding ended with Health Works for Women because health promotion was becoming more of a lifestyle. They were already sharing information about health promotion and supporting each other for making health changes; they had learned skills that would help them to continue.
I think it is becoming more of a lifestyle than it was. Because we buy things, we look at what we are buying now and we tell each other, well I found this and it tasted pretty good, and try this, and we are doing a lot of that. So with us we are trying to change it all the way around.
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Discussion |
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TopAbstractIntroductionMethodsEvaluationDiscussionReferences |
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This article describes the development, implementation and evaluation of a natural (lay) helping intervention for health promotion change, specifically designed and adapted to the culture and work situation of women in small rural blue-collar worksites. Although natural helper interventions have been conducted in a variety of settings, to our knowledge they have not been conducted in worksites for women's health promotion. This study demonstrates that women can be recruited and educated to successfully diffuse health promotion information to co-workers and support co-workers for behavioral change, through such an intervention. These findings are consistent with those who report the importance of social support for program participation and continuation (Emmons et al., 1996
).
Formative evaluation activities guided the strategies and content of this natural helping intervention and demonstrated the importance of being aware of relevant behaviors and attitudes that reflect cultural norms when developing such interventions (Bird et al., 1996; Sharp et al., 1998, Campbell et al., 1999). Because the issue of stress was an over-riding concern for women we included this as a component of the educational training, even though it was not part of the larger study. Paying attention to this helped establish rapport with the women and showed we were listening about the issues of most concern to them. Reputational methods were used to recruit women for this intervention (Jackson and Parks, 1997) but other methods were also used to assure that all social networks of women in the worksite were tapped and to be responsive to the cultural norms of women at the worksite. The importance of tapping all networks of women at the worksite was evident given that the natural helpers reported that information about health promotion was shared mostly with those in their own circles at the worksite.
Over time the natural helpers reported that the focus of diffusion of health promotion information shifted from family to co-workers and that, in addition to their bringing up health promotion in everyday conversation, co-workers more frequently approached them for this information. This approach was consistent with the culture of the women, who in focus groups expressed a hesitancy on the part of many women to tell others to change their health behavior (Tessaro et al., 1998). Thus, natural helping contacts became more responsive than proactive. A major value of the natural helpers in the worksites then is that they became known as someone from whom others could seek health promotion information.
The issue of time as a major barrier for women came up in the focus groups and was an important element for carrying out the program. Time constraints due to family obligations were especially problematic for the involvement of evening and night work shifts of women in this component of Health Works for Women. Because of this, written materials were often the preferred method of diffusing information about health promotion to women in their work areas, and breaks and lunch the best times for dissemination. Natural helpers were encouraged as part of their role to initiate group activities appropriate for women at the worksite, but given the time constraints and working schedules of women this was difficult. Group activities were done on a more limited basis but increased with time as women began to use the skills they learned in the training sessions. We were more successful with each succeeding worksite as we gained experience working with the natural helpers and a better understanding of the barriers that prevented women from developing group activities.
Two distinct patterns of the natural helping role were identified by qualitative evaluation: women who tended to get involved in the program because of a specific health concern or event with either themselves or others in their personal networks, and women who became involved within a broader conceptualization of health and prevention. Both types of natural helpers were able to take on the role of disseminating information about health promotion within the worksite and offered support to co-workers for behavior change and this increased over time for both groups. Such findings have implications for recruiting natural helpers and tailoring training sessions to fit with the individual helping style of different types of natural helpers in order to strengthen and expand their role. This also shows the importance of devoting enough time to the development of social network interventions and longitudinal evaluation to see effects of the intervention (Jamner et al., 1997).
More women than expected participated in the Natural Helpers program. This may have been because the health issues addressed were those of most concern to them, training sessions occurred at a time and place most found convenient, and because recruitment methods were inclusive. Several of the natural helpers were already thinking about making healthy changes but the Natural Helpers program seemed to give them the forum to learn, share and support each other to actually make changes. The group educational sessions provided the opportunity for women to talk with each other about health issues, to discuss their successes and failures in making health behavior changes, and to learn how to help themselves and other women change their health behavior. For women in these worksites the program provided the opportunity to increase their skills in how to share information about health promotion with others and encouraged them to become healthy role models for others.
There are limitations to the implementation of this social network intervention. There was little or no involvement from other health agencies and organizations in the larger community which could have made it a more sustainable program. There was no organizational component which could have fostered a link between the Natural Helpers program and management to encourage more environmental changes at the worksite, to assist in finding alternative ways to recruit and train women from the evening and night shifts, and to increase the likelihood of continuation after funding ended. In addition, changes in the North Carolina economy toward the end of the project period resulted in plant lay-offs and closings in the two textile companies that participated in Health Works for Women. Therefore, even though natural helpers were motivated to continue the program, many were forced to find new employment with accompanying disruption of their existing networks in the plants. Women may take this new found knowledge and spread this to other worksites, but this may be limited without the management support evident in this program.
Because women also diffused information about health promotion within their social networks outside the workplace, there may be additional benefits to this intervention in the larger community. Future research with social network interventions such as natural helping models of change, particularly those that use volunteers, should be directed toward network analysis to better understand to whom and how health promotion information is being diffused both within and outside the workplace, and how this varies by the natural helper role.
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Acknowledgments |
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This work was supported by grant no. U481CCU409660 from the Centers for Disease Control and Prevention awarded to the Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill
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Received on June 15, 1999; accepted on February 28, 2000
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